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1 A STUDY TO ASSESS THE EFFECTIVENESS OF BILLIG S EXERCISE IN REDUCING DYSMENORRHEA AMONG ADOLESCENT GIRLS AT GOVERNMENT HIGHER SECONDARY SCHOOL KALAPATTI, COIMBATORE By Reg. No: A DISSERTATION SUBMITTED TO THE TAMIL NADU Dr. M. G. R. MEDICAL UNIVERSITY, CHENNAI IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING OCTOBER 214

2 A STUDY TO ASSESS THE EFFECTIVENESS OF BILLIG S EXERCISE IN REDUCING DYSMENORRHEA AMONG ADOLESCENT GIRLS AT GOVERNMENT HIGHER SECONDARY SCHOOL KALAPATTI, COIMBATORE By Reg. No: Approved by EXTERNAL INTERNAL A DISSERTATION SUBMITTED TO THE TAMIL NADU Dr. M. G. R. MEDICAL UNIVERSITY, CHENNAI IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING OCTOBER 214

3 A STUDY TO ASSESS THE EFFECTIVENESS OF BILLIG S EXERCISE IN REDUCING DYSMENORRHEA AMONG ADOLESCENT GIRLS AT GOVERNMENT HIGHER SECONDARY SCHOOL KALAPATTI, COIMBATORE CERTIFIED THAT THIS IS THE BONAFIDE WORK OF Reg. No: PPG College of Nursing Coimbatore SIGNATURE : COLLEGE SEAL Dr. P. MUTHULAKSHMI, M.Sc(N)., M.Phil., Ph.D., Principal, PPG College of Nursing, Coimbatore A DISSERTATION SUBMITTED TO THE TAMIL NADU Dr. M. G. R. MEDICAL UNIVERSITY, CHENNAI IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING OCTOBER 214

4 A STUDY TO ASSESS THE EFFECTIVENESS OF BILLIG S EXERCISE IN REDUCING DYSMENORRHEA AMONG ADOLESCENT GIRLS AT GOVERNMENT HIGHER SECONDARY SCHOOL KALAPATTI, COIMBATORE APPROVED BY THE DISSERTATION COMMITTEE ON MARCH 213 RESEARCH GUIDE : Dr. P. MUTHULAKSHMI, M.Sc (N)., M.Phil, Ph.D., Principal, PPG College of Nursing, Coimbatore SUBJECT GUIDE : Prof. L. KALAIVANI, M.Sc(N)., Ph.D, Department of Obstetrical and Gynaecology Nursing, PPG College of Nursing, Coimbatore MEDICAL GUIDE : Dr. PADMAJA, M.D., Department of Medicine, Ashwin Hospital, Coimbatore A DISSERTATION SUBMITTED TO THE TAMIL NADU Dr. M. G. R. MEDICAL UNIVERSITY, CHENNAI IN PARTIAL FULFILLMENT OF REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING OCTOBER 214

5 Dedicated to Almighty God, Lovable Parents, Husband, Daughter Sister, Brothers, Friends & Well Wishers

6 ACKNOWLEDGEMENT I bow in reverence to the Lord almighty, the foundation of the knowledge and wisdom whose salutary benison enabled me to achieve this target. I owe my great sense of gratitude to my Grandmother Saraswathi Amma, for the foundation of the knowledge, wisdom and grace whose salutary benison enabled me to achieve the target. I am greatly indebted to My Husband Agish P.R, My Daughter Ardra Agish, Parents Father Mr. S Chandrasekharan Nair, Father in Law Mr. Ramachandran Nair, Mother Mrs. Komalavally, Mother in Law Late Ambikadevi, My Sister Miss. Vineetha, My Brother Mr. Sarin, Relatives for their love, support, prayer, encouragement and help throughout my study. I am grateful to Dr. L. P. Thangavelu, M.S., F.R.C.S, Chairman and Mrs.Shanthi Thangavelu, M.A,Correspondent of P. P. G Group of Institutions, Coimbatore and our trustees for their encouragement and providing the source of success for the study. It is my long felt desire to express my profound gratitude and exclusive thanks to Dr. P. Muthulakshmi, M.Sc (N), M. Phil., Ph.D., Principal, P. P. G college of nursing. It is a matter of fact that without her esteemed suggestions, high scholarly touch and piercing insight from the inception till the completion of the study, this work could not have been presented in the manner it has been made. Her timely encouragement supported me a lot throughout my study, which is truly immeasurable

7 and also express my gratitude for her valuable guidance, and help in the statistical analysis of the data, which is the core of the study. It is a great privilege to express my sincere thanks and deep sense of indebtedness to my esteemed subject guide Prof. L. Kalaivani, M.Sc (N), Ph.D, Professor in obstetrics and Gynecology Department for her keen support, encouragement, guidance, valuable suggestions and constructive evaluations which have enabled me to shape this research as a worthy contribution. I extend my sincere thanks to Prof. B. Rajalakshmi, M.Sc(N)., Ph.D, Prof. K. Jeyabarathi, M.Sc (N)., Ph.D, Asst. Prof. J. Nagamala, M. Sc(N)., Ph.D, Asst. Prof. D. V. Syamala, M.Sc(N), Ph.D, Lecturers Miss. Vijayalakshmi, M.Sc(N)., and Mrs. Sangeetha, M.Sc (N) Ph.D, and all the other Faculty Members of P.P.G College of Nursing for their healthy criticism, supportive suggestions and tremendous cooperation for completing my work successfully. I extend my sincere thanks to Mrs. Manibharathi, M.Sc(N)., Ph.D, (Class Coordinator) for her esteemed suggestions, constant support, timely help and guidance till the completion of my study. I express my sincere thanks to the Principal, Government Higher Secondary School, Kalapatti, Coimbatore for granting permission to conduct the study in their school, and I extend my grateful thanks to the teaching and non teaching staffs for their co- operation and help for completing my work successfully.

8 I extend my thanks to the Dissertation Committee Members for their healthy criticism, supportive suggestions which moulded the research. I express my sincere gratitude to Prof. V. Venugopal, statistician, for the expert guidance and suggestions in the statistical analysis of the data. I take this opportunity to thank the Experts who have done the content validity and valuable suggestions in the modifications of the tool. I would express my sincere thanks to Mr. N. Siva Kumar of Nawal Comtech Solutions, Saravanampatti for his patience, dedication and timely co- operation in typing this manuscript. I owe a great deal of thanks to my dear most colleagues who encouraged and supported me with their time and valuable suggestions throughout my study. I extent my thanks to all the participants in the study. I thank all my well wishers who helped me directly and indirectly.

9 LIST OF CONTENTS CHAPTER CONTENTS PAGE No. I INTRODUCTION Need for the Study Statement of the Problem Objectives Hypothesis Operational Definitions Assumptions II REVIEW OF LITERATURE Conceptual Frame Work 8 16 III METHODOLOGY Research Approach Research Design Setting of the Study Variables Population Sample Size Sampling Technique Criteria for Selection of Samples Description of the Tool Testing of the Tool Pilot Study Data Collection Procedure Plan for Data Analysis

10 CHAPTER CONTENTS PAGE No. IV DATA ANALYSIS AND INTERPRETATION 27 V RESULTS AND DISCUSSION 56 VI SUMMARY, CONCLUSION, NURSING IMPLICATIONS, LIMITATIONS AND RECOMMENDATIONS REFERENCES ABSTRACT APPENDICES 6

11 LIST OF TABLES S.No. CONTENT PAGE No. 1. Description of Demographic Variables of Adolescent Girls with Dysmenorrhoea Regarding the Effectiveness of Billig s Exercise in Reducing Menstrual Pain in Experimental and Control Group at Government Higher Secondary school Kalapatti, Coimbatore. 2. Distribution of Statistical Value of Pre- Test Score Regarding Menstrual Pain Among Adolescent Girls of Experimental and Control Group at Government Higher Secondary School, Kalapatti, Coimbatore 3. Distribution of Statistical Value of Pre- Test and Post- Test Score Regarding Menstrual Pain Among Adolescent Girls of Experimental Group at Government Higher Secondary School, Kalapatti, Coimbatore 4. Distribution of Statistical Value of Pre- Test and Post Test Score Regarding Menstrual Pain Among Adolescent Girls of Control Group at Government Higher Secondary School, Kalapatti, Coimbatore 5. Distribution of Statistical Value of Post Test Score Regarding Menstrual Pain Among Adolescent Girls of Experimental and Control Group at Government Higher Secondary School, Kalapatti, Coimbatore 6. Association of Selected Demographic Variables with Post Test Score Regarding Menstrual Pain Among Adolescent Girls at Government Higher Secondary School Kalapatti, Coimbatore

12 LIST OF FIGURES S. No. CONTENTS PAGE No. 1. Modified Conceptual Framework Based on Ernestine Wiedenbach s Helping Art of Clinical Nursing Theory (1964) 2. The Schematic Representation of the Study Design in Experimental Group The Schematic Representation of the Study Design in Control Group 2 4. The Schematic Representation of the Variables The Overall View of Research Methodology Graphical Representation of Demographic Variables of Adolescent Girls According to the Age of the student in Both Experimental and Control Group 7. Graphical Representation of Demographic Variables of Adolescent Girls According to the Education in Both Experimental and Control Group 8. Graphical Representation of Demographic Variables of Adolescent According to BMI in Both Experimental and Control Group 9. Graphical Representation of Menstrual Variables of Adolescent Girls According to Age at Menarche in Both Experimental and Control Group 1. Graphical Representation of Menstrual Variables of Adolescent Girls According to Duration of Menstruation in Both Experimental and Control Group 11. Graphical Representation of Menstrual Variables of Adolescent Girls According to the Duration of Menstrual Pain in Both Experimental and Control Group

13 S. No. CONTENTS PAGE No. 12. Graphical Representation of Menstrual Variables of Adolescent Girls According to Flow of Menstruation in Both Experimental and Control Group 13. Graphical Representation of Menstrual Variables of Adolescent Girls According to the Nature of Menstrual Pain in Both Experimental and Control Group 14. Graphical Representation of Menstrual Variables of Adolescent Girls According to the Location of Menstrual Pain in Both Experimental and Control Group 15. Graphical Representation of Menstrual Variables of Adolescent Girls According to the Psychological Disturbances During Menstruation in Both Experimental and Control Group 16. Graphical Representation of Statistical Value of Pre-test Pain Score Regarding Pain During Menstruation Among Adolescent Girls of Experimental and Control Group 17. Graphical Representation of Statistical Value of Pre-test and Post Test Score Regarding Pain During Menstruation Among Adolescent Girls of Experimental Group 18. Graphical Representation of Statistical Value of Pre-test and Post Test Score Regarding Pain During Menstruation Among Adolescent Girls of Control Group 19. Graphical Representation of Statistical Value of Post Test Pain Score Regarding Pain During Menstruation Among Adolescent Girls of Both Experimental and Control Group

14 LIST OF APPENDICES APPENDIX TITLE 1. Letter seeking permission for conducting the study 2. Letter seeking permission from Experts for content validity of the tool 3. Format for the content validity 4. List of experts for content validity 5. Questionnaire Numeric Pain Intensity Scale for Dysmenorrhoea English Tamil 6. Protocol English

15 A STUDY TO ASSESS THE EFFECTIVENESS OF BILLIG S EXERCISE IN REDUCING DYSMENORRHEA AMONG ADOLESCENT GIRLS AT GOVERNMENT HIGHER SECONDARY SCHOOL KALAPATTI, COIMBATORE

16 1 CHAPTER - I Introduction Movement is a medicine for creating change in a person s physical, emotional and mental status - Carol Welch Alan R (29) stated that the term adolescence is derived from the Latin word adolescere which means to grow up. It is a traditional stage of physical and psychological human development generally occurs from puberty to legal adult hood. Keane M (21) explained that adolescence is a period of life from puberty to adulthood characterized by marked physiological changes, development of sexual feelings, efforts towards the construction of identity, and a progression from concrete to abstract thought. It is viewed as a transitional state, in which youths begin to separate themselves from their parents but still lack a clearly defined role in society. It is generally regarded as an emotionally intense and often stressful period. Gavin M L (21) stated that menstruation (a period) is a major stage of puberty in girls; it's one of the many physical signs that a girl is turning into a woman. Menarche is the onset of menstruation and it is one of the most significant milestones in a woman's life. The mean age at menarche varies from population to population and is known to be a sensitive indicator of various characteristics of population including nutritional status, geographical location, environmental conditions and magnitude of socioeconomic inequalities in a society. For most females, it occurs between the age of 1 and 16 years; however, it shows a remarkable range of variation. The normal range for ovulatory cycles is between 21 and 35 days. While

17 2 most periods last from three to five days, duration of menstrual flow normally ranges from two to seven days. For the first few years after menarche, irregular and longer cycles are common. Emel Urun (26) explained that dysmenorrhoea is one of the common problems experienced by many adolescents girls. There are two types of dysmenorrhoea, primary and secondary. The primary dysmenorrhoea is a periodic pain and cramps. It may last for 1-3 days of periods, when the chemical messenger called prostaglandin peak. Secondary dysmenorrhoea is a cramps caused by medical problems. Rahma. Al. Kindi (211) stated that, dysmenorrhoea is highly prevalent during adolescence, ranges from 6%to 93%. About 15% of adolescent describe their dysmenorrhoea as severe. There are pharmacological methods which are used for treating dysmenorrhoea. Preventive measures include exercise, massage and medication. Gregory J Boyle (24) stated that, physical exercise has been suggested as a non medical approach for managing the symptoms of dysmenorrhoea. It has been found useful to affect menstruation on many ways. Billig s exercises is one of the effective exercise for adolescents to relieve menstrual discomforts. It is an exercise which stretches the connective tissue around the pelvis, hip flexors and muscles of the abdomen. William P. Metheny (29) explained that alleviation of dysmenorrhoea may result for better mood, increases the sence of control and boosts the energy level. It

18 3 not only feels better by releasing endorphins (naturally occurring chemical in brain) which are reducing cramps but also strengthens the muscles in buttocks and thighs and help in the synthesis of prostaglandins, which may cause pain and help the adolescents to have a normal menstruation. Midwives can play an important role in the transitional stages of adolescents developed especially the uncharted terrains of puberty, which everything is in flux. Being prepared and anticipating these changes helps the growing process dramatically and decreases fear and anxiety about the changes. Need for the Study Santina T (21) stated that dysmenorrhoea is a gynaecological condition of pain during menstruation that interferes with daily activities among adolescent girls with prevalence of 65 9%, but it is also frequent among young adult women under 3 years of age. It is the leading cause of absenteeism in school among this age group. Avasarala A. K (21) noticed that the prevalence of dysmenorrhoea world wide is with rates ranging from %.With higher prevalence rates reported in adolescents population. Panchangam S (21) concluded that 87.87% of adolescent girls are suffered from dysmenorrhoea in Tamil Nadu. Geng M. C (21) conducted a study on menstrual problems in rural areas of Tamilnadu among 55 school students. The study reported that, 38% school

19 4 absenteeism due to dysmenorrhoea and the activities affected by dysmenorrhoea include concentration in the class (59%), sports (51%), participation in the class (5%), socialization (49%), home work (35%), test taking skills (36%) and grades (29%). Davins A.R, et.al, (211) conducted a study on prevalence, associated morbidity and treatment of primary dysmenorrhoea among 97 adolescent girls and the result obtained was that the prevalence of the dysmenorrhoea was found to be 6-9% and 15% of adolescents described their dysmenorrhoea as severe. Dysmenorrhoea leads to high rates of school absence and activity non participation. Most adolescent with dysmenorrhoea self-medicine with over the counter preparations, few consult health care providers. Amanda J Daley (26) explained that many adolescent girls are familiar with the experience of dysmenorrhoea, which can contribute to significant physical and emotional distress and life disruption. It is important to assess the beliefs and experiences of all women with dysmenorrhoea including adolescents as early in gynaecologic care as possible. Exercise is an effective method for relieving menstrual symptoms. Gregory J Boyle (24) stated that, most of the adolescents feels that exercise is one of the effective method for treating dysmenorrhoea. In that Billing s, one of the first advocates of exercises for dysmenorrhoea in 1943, when a women with dysmenorrhoea have a contracted ligamentous bands in the abdomen. While exercising subsequently developed a series of stretching in the abdomen and pelvic

20 5 muscle, which claimed a high rate of symptom relief. This exercise was beneficial continued to enjoy wide spread acceptance with the evidence being mainly anecdotal. Rima Gupta (213) conducted a quasi experimental study to assess the effectiveness of active exercise on primary dysmenorrhoea among adolescent girls with 64 students between the age group of years. A standardized tool ie, numerical rating pain score and menstrual distress questionnaire were used for assessing the severity of dysmenorrhoea. The study results reveal that, the active exercise is effective in reducing the menstrual pain. Jerdy et.al, (212) conducted an experimental study to assess the effectiveness of stretching exercise on dysmenorrhoea in adolescent girls which the subjects were requested to do for 8 weeks at home. He found that, stretching exercise are effective in reducing pain intensity, pain duration and the amount of pain killers used by girls with dysmenorrhoea. By considering the review of literature, viewing the extent of the problem and understanding the advantages of Billig s exercise in the reduction of dysmenorrhoea, the researcher felt need for assessing the effectiveness of Billig s exercise in reduction of dysmenorrhoea by using self administered numerical pain scale. Statement of the Problem A study to assess the effectiveness of Billig s Exercise in reducing dysmenorrhea among Adolescent girls at government higher Secondary school Kalapatti, Coimbatore.

21 6 Objectives To assess the level of dysmenorrhoea among adolescent girls in the experimental and control group. To administer Billig s exercise for adolescent girls with menstrual pain in experimental group. To assess the effectiveness of Billig s exercise on menstrual pain among adolescent girls in experimental group. To compare the level of dysmenorrhoea among adolescent girls in the experimental and control group. To associate the level of dysmenorrhoea among adolescent girls with selected demographic variables. Hypothesis H 1 : There is a significant difference between pre test and post test score of pain after administering Billig s exercise among adolescent girls at Government girls higher secondary school, Coimbatore. So there will be a significant effect of Billig s exercise in reducing dysmenorrheal among adolescent girls. Operational Definitions Effectiveness It refers to the extent to which Billig s exercise help in reducing dysmenorrhoea as determined by significant difference in pretest and post test scores.

22 7 Dysmenorrhoea In this study, it refers to the intensity of pain expressed by the adolescent girls during menstruation. Billig s Exercise In this study it refers to the pelvic tilt along with tightening of buttocks and muscles of abdomen followed by relaxation, which persists for 1-15 seconds and repeated 5-6 times a day during menstruation. Adolescent In this study it refers to the girls between the age group of years, who are attained menarche and having pain during menstruation. Assumptions Dysmenorrhoea patients experiences pain and it will affect the students day to day activities. They need alternative therapy for relief of pain. Billig s exercise helps to reduce pain during menstruation. After the practice of Billig s exercise they feel relief of pain.

23 8 CHAPTER II Review of literature Review of literature lays foundation for a study and can also influence for new research ideas. A literature review plays a role at the end of the study, when researcher is trying to make sure of their feelings (Polit, 29). Review of literature was done for the present study which is presented in the Following Heading Literature review related to prevalence of dysmenorrhea. Literature review related to effectiveness of Billig s exercise. Literature Review Related to prevalence of Dysmenorrhea French. L (29) conducted a study to find out the prevalence of dysmenorrhea among adolescent girls and its effect on recurrent short term school absence and the result obtained was the prevalence of dysmenorrhea was 75% and 2% seeks medical advice for menstrual pain. In majority of cases, the pain starts with the onset of menses and lasts 1-3 days. Suresh K. Kumbhar (211) A cross sectional study was conducted among 183 adolescent girls ( 14-19yrs) in schools and colleges at Kadapa town, Andrapradesh using a semi structured questionnaire to estimate the prevalence of dysmenorrhea and its impact on quality of life among adolescent girls. The result reported that, out of 183 adolescent girls, 119(65%) were dysmenorrheic, 68.4% and 61.2% were from the urban and rural areas respectively. Out of 81 adolescent girls with family history of

24 9 dysmenorrhoea 6 (74.1%) adolescent girls were dysmenorrheic. Sickness absenteeism was seen among 47.9% dysmenorrhoric girls. Quality of life was significantly reduced among adolescent girls. Almost 73.1% of rural girls relied on self help technique to manage the dysmenorrhea as compared to urban girls (55.2 %). Latte P M, et.al, (211 ) conducted a cross sectional study on prevalence of dysmenorrhea among college students to determine the effect on health related quality of life and the prevalence was found to be 68.7% and was significantly higher in coffee consumers, menstrual bleeding more than 7 days and those who have family history of dysmenorrhea. Agarwal A K, et.al, (21) conducted an exploratory study on prevalence of dysmenorrhea and the severity of problem with associated symptoms and general health status among high school adolescent girls of Gwalior and the result obtained was the prevalence of dysmenorrhea in adolescent girls was 76.67% and the three most common symptoms present on both days, that is day before and first day of menstruation were lethargy and tiredness, depression and inability to concentrate in work. Davis A R, et.al, (211) conducted a study on prevalence, associated morbidity and treatment of primary dysmenorrhea among 97 adolescent girls and the result obtained was that the prevalence of dysmenorrhea was found to be 6-9% and 15% of adolescents described their dysmenorrhea as severe. Dysmenorrhea leads to high rates of school absence and activity non- participation. Most adolescent with dysmenorrhea self medicate with over the counter preparations, few consult health care providers.

25 1 Malhotra C, et.al, (28) conducted a study to assess the types and frequency of problems related to menstruation among adolescent girls and the effect of these problems on daily routine.more than a third ( 35.9%) of the study subjects were in the age group years followed by years, years respectively. Mean age of the study participants were calculated to be 16.2 years. Dysmenorrhea (67.2%) was the commonest problem and 63.1% had one or the other symptoms of premenstrual syndrome (PMS). Other related problems were present in 55.1% of study subjects. Daily routine of 6% girls were affected due to prolonged bed rest, missed social activities / commitments, disturbed sleep and decreased appetite % had to miss classes and 25% had to abstain from work. Cynthia. F, et.al, (21) conducted a study on prevalence of dysmenorrhea among adolescent girls and the result obtained was found to be % and dysmenorrhea seems to be the most common gynecological condition in women regardless of age and nationality. Jackson. C (21) conducted an epidemiological study of the prevalence of dysmenorrhea in 423 middle and high school students and the result was found to be 21% with 92 dysmenorrheic adolescents in that 453 were in the age group of years and 449 were in the age group of years. 98% of the adolescent reported pelvic pain, 7% asthenia, 59% low back pain, and 3% reported nausea and vomiting. Saha. R (211) conducted a cross sectional study to assess the incidence of dysmenorrhea and menstrual hygiene practices among adolescent girls from selected schools the study sample consists of 16 students. The results revealed a high

26 11 prevalence (94.4%). Measures taken to relieve dysmenorrhea were found to be: intake of certain types of domestic hot drinks (43.%), taking analgesics (22.5%), and (66.2%) performed physical activities during menstrual period to relieve pain. Francoise (212) conducted an exploratory study on etiology of dysmenorrhea among adolescent girls and found that an elevated level of prostaglandin has been found in the menstrual blood of adolescent girl with dysmenorrhea. The prostaglandin mediates the pain sensation and stimulates endometrium contraction and increased urinary secretion of leukotrienes E(4) inflammatory mediators known to cause potent vasoconstriction and uterine contractions cause dysmenorrhea symptoms in adolescents. Literature Review Related to Billig s Exercise on Dysmenorrhea Jima Mathew (213), an experimental study was conducted in selected schools in Karnataka, Mangalore to assess the effectiveness of billig s exercise on dysmenorrhea. The researcher take 168 adolescent girls in selected schools. The study results revealed that, the intensity of pain is reduced in about 72.8% of the students. Abbaspour (21) an experimental study was conducted to estimate the effect of exercise on dysmenorrhoea among 25 adolescents in Iran. About 55 percent of adolescents were suffering from dysmenorrhoea. The researcher assessed the effect of 12 week physical fitness programme on psychological and physical symptoms of dysmenorrhoea. The result showed that the training programme contributed to substantial reduction in dysmenorrhoea from 55 to 39 percent. The researcher concluded that selected physical fitness exercises positively influenced menstrual symptoms.

27 12 Metheny. W. P (29) conducted a study in Georgia considers primary dysmenorrhea from a biopsychosocial perspective in examining the relationship between physical exercise and menstrual pain. Despite widespread claims of the benefits of exercise for perimenstrual symptoms, the evidence seems weak. Stronger evidence indicates that exercise helps relieve stress and elevates mood and that stress heightens menstrual discomfort. Student nurses (n = 176) completed a questionnaire distinguished as a general health survey that contained these measures. The hierarchical regression analysis demonstrated that, contrary to the expected, regular exercise increased with the severity of menstrual symptoms, after controlling for medications, disposition, perceived stress, and mood. The findings suggest that exercise presents a trade off; it relieves the stress that may intensify dysmenorrhea, yet it may aggravate the same symptoms. Br. J.Gen Pract (29) a study was conducted on billig s exercise on primary dysmenorrhea. In this study he takes n= 36 students with dysmenorrhea, only 26 participants completing the follow up. The study reveals that, exercise can reduce the intensity of pain in adolescent girls. Suckling. J (29) conducted a randomized clinical trial study to determine the effect of exercise on primary dysmenorrhea among 15 high school girls in Chennnai city and the result obtained was that the intensity of the pain in the exercise group declined from 8.59 to 4.63 in the third menstrual period and in the fourth menstrual period and 2.84 in the fourth menstrual period.the average of the duration of pain declined from 7.15 to 4.22 in the third menstrual period. In conclusion the exercise can decrease the duration and severity of dysmenorrhea.

28 13 Pattison. H. M (29) conducted an experimental study among 69 technical college female students in Taiwan to assess the effects of exercise on dysmenorrhea. Five tools were used to collect pretest and post test data in each section. Thirty one of the experimental participants reported that exercise was helpful, a thirty three were satisfied with exercise and concluded that exercise was effective to reduce pain and anxiety during menstruation. Morse (26) commented that approximately 1% of the women were severely affected by dysmenorrhoea during the reproductive years. Relaxation instructions are provided to a experimental group and drug treatment were given to control group. The study revealed that experimental group have significant positive benefits from the relaxation technique. Dos Santos (24) conducted a study on pain management. The subjects were 61 patients with menstrual symptoms given relaxation technique for 24 weeks and various treatment are proposed. The result showed that subjects pain level are decreased after getting billig s relaxation technique. Mariyam Rostami (27) conducted a study to determine the effect of exercise on primary dysmenorrhoea in high school girls. The study was randomised clinical trial of 15 students suffering from severe dysmenorrhoea, two groups - exercise group and non exercise group assessed the intensity of pain, duration of pain, number of medicines used for two periods. The intensity of pain in the exercise group reduced from 8.59 to 4.63 in the 3rd period and 2.84 in the 4th period. The average duration declined from 7.15 hours to 4.22hrs in 3rd period and 2.23 in the 4th period. The

29 14 average use of sedative tablets also decreased from 1.3 tablets to.35 in the 3rd period and. tablets in the 4th period. Blakey, et.al., (28) conducted the study on 654 university students aged between 18 and 25 at College of Medical and Dental Sciences. The participants were evaluated for their age, height, weight, ethnicity, and current smoking behaviour through the Women s Health and Lifestyle Questionnaire. The researchers also used a modified version of the Godin Leisure-Time Exercise Questionnaire to analyze the exercising pattern of the study participants. The response rate noted during the study was 91.3%. Menstrual pain rating using a visual analogue scale (VAS) and the verbal multidimensional pain score (VMPS) demonstrated that participating in physical exercise would not confer any reduction in PD. Julie. A. Aganoff, et.al, (26) conducted a study to examine the effect of regular moderate exercise on mood states and menstrual cycle symptoms at Australia. A group of female regular exercisers (N=97), and a second group of female non exercisers (N=159), completed the Menstrual Distress Questionnaire (MDQ) and the Differential Emotions Scale (DES-IV) Premenstrualy, Menstrually and Intermenstrually. Multivariate Analyses of Covariance (MANCOVAS) revealed significant effect for exercise on negative mood states and physical symptoms, and significant effects on all measures across menstrual cycle phase. The regular exercises obtained significantly lower scores on impaired concentration, negative effect, behavior change and pain. No differences were found between groups on positive effect and other physical symptoms.

30 15 Saher. M. Soliman (212) conduced an experimental study was conducted to assess the effectiveness of pelvic rocking exercise for dysmenorrhoea among 3 adolescent girls in Tamilnadu. The subjects were selected by lottery method to the experimental group and were administered pelvic rocking exercise. After 3 weeks, post-test score showed that pain had decreased from eight to four. The researcher concluded that pelvic rocking exercise was effective in the reduction of dysmenorrhoea among adolescent girls. Therefore, pelvic rocking exercise can be used as a supportive therapy in adolescents to alleviate dysmenorrhoea. Jerdy, et.al, (212) conducted an experimental study to assess the effectiveness of stretching exercise on primary dysmenorrhoea in adolescent girls which the subjects were requested to do for 8 weeks (3 days per week, 2 times per day, 1 minutes each time) at home. He found that stretching exercise were effective in reducing pain intensity, pain duration and the amount of pain killers used by girls with primary dysmenorrhoea. Rima Gupta (213) A quasi experimental study was conducted in two colleges of nursing, to assess the effectiveness of active exercise on primary dysmenorrhoea among adolescent girls with 64 students between age group of years. A standardized tool ie, numerical rating pain score and menstrual distress questionnaire were used for assessing the severity of primary dysmenorrhoea. The study results reveal that the active exercise is effective in reducing the menstrual pain.

31 16 Conceptual Framework The concept is a thought frame or mental images in mind in response to learning something new. A framework is a basic structure supporting anything. A conceptual framework deals with abstraction (concept), which is assembled by nature of their relevance to a common theme (Christenson, 199). According to Wiedenbach s the practice of nursing comprises a wide variety of services based on goal directed care. It consists of three steps Step 1 : Identify the Need for Help Identification involves viewing the patient as an individual with unique experiences and understanding the patient s perception of the condition. It includes the following components. General Information This comprises of the demographic variables Central Purpose Central purpose is to reduce the dysmenorrhea. Prescription It includes the intervention to meet the central purpose that is providing billig s exercise. Step 2 : Ministering the Needed Help Ministration refers to provision of needed help. Agent The agent is the practicing nurse or a designee who has the personal attributes, capacities and competence to provide nursing care. Here the agent was nurse investigator.

32 17 Recipient The adolescent girl who are having menstrual pain. Goal It is the nurses desired outcome. Here the goal is to reduce the pain of adolescent girls who is having the menstrual pain. Means Means are the activities and the device used by the nurse investigator to achieve the goal. Here the nurse investigator used the Billig s exercise. Framework It refers to the facilities in which the nursing care is provided. Here the framework is Govt. Higher Secondary School, Kalapatti, Coimbatore. Step 3 : Validating that the Need for Help was Met Validation refers to adolescent girl functional ability that was restored as a result of the help given. It is validated that the needed help was delivered in achieving the central purpose. This step involves the post test done after ministering the help and analysis was done to make suitable decision and recommendation action to continue or modify the nursing action.

33 18 NURSING IDENTIFY THE NEED FOR HELP MINISTERING THE NEEDED HELP VALIDATING THE NEED FOR HELP GENERAL INFORMATION DEMOGRAPHIC VARIABLES Age, Religion, Education, BMI, Age At Menarche, Frequency of menstruation, Flow of menstruation, Nature of menstruation, Location of menstrual pain, Duration of Pain, Absenteeism in School REALITIES 1. Agent : Nurse investigator 2. Recipient : Adolescent girls with menstrual pain 3. Goal : To reduce menstrual pain 4. Mean of activity : Billig s exercise 5. Framework : Govt. Higher Secondary School Kalapatti ANALYSIS To associate the findings with selected variables and to assess the effect of Billig s exercise in reducing menstrual pain Billig s exercise Assessment of pain level in experimental and control group Planning for providing Billig s exercise in experimental group Providing Billig s exercise in experimental group No intervention in control group Significant reduction in menstrual pain No significant reduction in menstrual pain Feed back Figure. 1 Modified Conceptual Framework Based on Ernestine Wiedenbach s Helping Art of Clinical Nursing Theory (1964)

34 19 CHAPTER - III Research Methodology Methodology is the study which indicates the general pattern of the research approach and research design that includes the steps of procedures and strategies and analyzing the data in the investigation. This chapter explains the methodology adopted by the researcher to assess the effectiveness of Billig s exercise on dysmenorrhoea among adolescent school students in Government Girls high School Kalapatti, Coimbatore. It deals with the research approach, research design, setting of the study, variables, population, sample size, sampling technique, criteria for selection samples, description of the tool, pilot study, data collection procedure and plan for data analysis. Research Approach Experimental approach is a subtype of quantitative research approach was used for the present study. Research Design The research design provides an overall plan for conducting the study. Pretest post test experimental and control group design was adopted for the present study. The researcher took two groups experimental and control group. The pre-test measurement was assessed by means of a numerical pain rating scale from adolescent girls. In both the experimental and control group which was

35 2 depicted as O 1 and O 3 respectively. The Billig s exercise was provided to the experimental group for 1day before menstruation and first 2 days of menstruation, 5-6 times a day for 2 minute which was depicted as X. The post test was conducted using same numerical pain scale from both the group which was depicted as O 2 and O 4. E - O 1 X O 2 C - O 3 X O 4 E - Experimental group O - Observation O 1 - Pretest O 2 - post test O 3 Pretest O 4 Post test X - Billigs exercise C Control group O 1 X O 2 Assessing the level of dysmenorrhoea among adolescent girls in experimental group Intervention with providing Billig s exercise Reassessing the level of dysmenorrhoea among adolescent girls in experimental group Figure. 2 The schematic Representation of the Study Design in Experimental Group O 3 O 2 Assessing the level of dymenorrhoea among adolescent girls in control group Reassessing the level of dysmenorrhoea among adolescent girls in control group Figure. 3 The schematic Representation of the study design in Control Group

36 21 Setting of the Study The study was conducted among adolescent school students in Government. Girls Higher Secondary School Kalapatti, Coimbatore, about 3 students, which is situated 4km from PPG College of Nursing. Variables The dependent variable was the pain level of dysmenorrhoea. Independent variable was live demonstration regarding Billigs exercise. The influencing variables were demographic variables such as age, education, religion, BMI, age at menarche, duration of menstruation, frequency of menstruation, duration of menstrual pain, flow of menstruation, location of menstrual pain, associated symptoms during menstruation, psychological disturbances during menstruation, medication, interference of the study due to menstrual pain. Influencing Variables Dependent Variables Independent Variables Demographic variables such as age, education, religion, BMI, age at menarche, duration of menstruation, frequency of menstruation, duration of menstrual pain, flow of menstruation, location of menstrual pain, associated symptoms during menstruation, psychological disturbances during menstruation, medication, interference of the study due to menstrual pain Dysmenorrhoea among adolescent school students Live demonstration on Billig s exercise Figure. 4 The Schematic Representation of the Variables

37 22 Population The population of the study includes the adolescent girls who are studying in 8 th, 9 th, 1 th and11 th standard with menstrual pain at Govt. Higher Secondary School Kalapatti, Coimbatore. Sample Size The sample size was included for this study consists of 6 adolescent girls who fulfilled the inclusive criteria, with experimental group 3 and control group 3. Sampling Technique The samples were selected using purposive sampling technique, a type of non probability sampling method. Criteria for Selection of Samples Inclusive Criteria Adolescent girls students who are suffering from dysmenorrhoea. Adolescent girls students who are available during the period of data collection. Adolescent girls students who are willing to participate in this study. Adolescents girls who have attained menarche and are in the age group of years. Exclusive Criteria Adolescent girls who are not willing to participate. Adolescent girls who are undergoing treatment by physician for dysmenorrhoea.

38 23 Description of Tool The researcher had developed a tool after referring the review of literature to assess the menstrual pain and get the opinion from experts of Obstetrics and Gynaecologic departments to assess the effectiveness of Billig s exercise to reduce dysmenorrhoea among adolescent girls. The tool contains the following sections. Section - A Demographic Variables and Menstrual Variables Demographic variables and menstrual variables which include age, body mass index, duration of menstruation, flow of menstruation, age at menarche, nature and location of menstrual pain, associated symptoms during menstruation, inference of the study due to menstruation. Section - B Self Administered Numerical Pain Scale Self Administered numerical pain scale was used to measure the pain experienced by the adolescent girls during the menstruation period. This scale is marked from - 1 encompassing 1 equal division 1, 2, 3, 4, 5, 6, 7, 8, 9, and 1. The pain intensity is a subjective experience and the difference between minimum pain and maximum pain could be measured objectively with equally divided numerical digits As the level of scores increases, the intensity of pain also increases. In this scale, pain intensity was scored arbitrarily as follows. No pain 1-3 Mild 4-6 Moderate >7 - Severe

39 24 Testing of the Tool Content Validity The tool was given to six experts of obstetrics and gynaecological nursing. All suggestions and comments given by them were duly considered and corrections were made after discussion with the research guide. Reliability of the Tool The tool is highly reliable because the scale used was standardized. The reliability of the tool was obtained by spearman split half technique. The reliability of numerical pain intensity scale was.738. Hence the reliability of the tool was satisfactory. Pilot Study The pilot study was conducted to make sure that the tool was capable of eliciting responses from respondents. It was conducted among 6 samples for a period of one week, 3 for experimental group and 3 for control group at Govt. Higher Secondary school, Kalapatti, Coimbatore. The pretest was conducted by using the numerical pain scale from the experimental and control group. Soon after the pretest, the Billig s exercise are taught to the adolescent girls in the experimental group for one day before menstruation, day1 and day2 of menstruation 5-6 times a day. Post test was done by using same numerical pain scale in both the groups. The pilot study showed that there was a decrease in the pain level in post test of experimental group compared to the control group. Data Collection Procedure The formal permission was obtained from the Principal of Govt. Higher Secondary School Kalapatti, Coimbatore to conduct the study with assurance to abide

40 25 by the rules and regulations of the school. The study was done for the period of one month from to The samples were selected by purposive sampling technique on the basis of inclusion criteria. Informed consent was taken from the samples. Out of 6 samples, 3 were considered as experimental group and 3 were considered as control group. After the general instructions, the investigator collected the demographic and menstrual data. Pre test was done by means of pain rating scale from both experimental and control group. After the pretest, intervention through providing Billig s exercise was given to the experimental group on day before menstruation, day 1 and day 2 of menstruation, 5-6 times a day. Post test was done to assess the level of dysmenorrhoea among both groups by using same numerical pain scale. Plan for Data Analysis Descriptive statistics were used to analyze the frequency, percentage, mean, standard deviation of the following variables. Inferential statistics were used to determine the relationship and comparison to identify the difference. Paired t test was used to compare the pretest and post test score of pain of adolescent girls with dysmenorrhoea. Independent t test was used to compare the pain score of adolescent girls with dysmenorrhoea of both the experimental and control group. Chi- square test was used to assess the association between menstrual pain score with selected demographic variables.

41 26 Quantitative Approach Study setting: Govt Higher Secondary School Kalapatti, Coimbatore Population: Adolescent Girls with Dysmenorrhea Sampling technique: Purposive Sampling technique Sample size: (N=6), Experimental Group: (n= 3), Control Group: (n=3) Pre Test: Level of Pain During Menstruation Among Adolescent Girls in Both Group Experimental Group: Administering billig s exercise Control Group: No intervention is given Post test: Level of Pain During Menstruation Among Adolescent Girls in Both Group Data Analysis: Descriptive and Inferential Statistics Study Findings and Conclusion Figure. 5 The Overall View of Research Methodology

42 27 CHAPTER IV Data Analysis and Interpretation This chapter deals with the analysis and interpretation of data collected from the adolescent girls, to assess the effectiveness of Billig s exercise in reducing menstrual pain among adolescent girls at Government Higher Secondary School, Kalapatti, Coimbatore. The findings based on the descriptive and inferential statistics analysis were presented under the following headings. Section I : Description of demographic variables of adolescent girls with dysmenorrhea regarding the effectiveness of billig s exercise on reducing menstrual pain in experimental and control group at Government Higher Secondary School, Kalapatti, Coimbatore. Section II : Distribution of statistical value of pretest score regarding menstrual pain among adolescent girls of experimental and control group. Section III : Distribution of statistical value of pretest and posttest score regarding menstrual pain among adolescent girls of experimental group. Section IV : Distribution of statistical value of pre test and post test score regarding menstrual pain among adolescent girls of control group. Section V : Distribution of statistical value of post test score regarding menstrual pain among adolescent girls of experimental and control group. Section VI : Association of selected demographic variables with post test score regarding menstrual pain among adolescent girls with dysmenorrhea in experimental group.

43 28 SECTION - I Table. 1 Description of Demographic Variables of Adolescent Girls with Dysmenorrhoea Regarding the Effectiveness of Billig s Exercise in Reducing Menstrual Pain in Experimental and Control Group at Government Higher Secondary school Kalapatti, Coimbatore (N = 6) S.No. Demographic Variables Experimental group (n = 3) Control group (n = 3) f % f % 1. Age of the student a) years b) years Education a) 8 th standard b) 9 th standard c) 1 th standard d) 11 th standard Religion a) Hindu b) Christian c) Muslim BMI a) < b) c) > d) > 3 (Table 1 continues)

44 29 (Table 1 continued) S.No. Demographic Variables Experimental group (n = 3) Control group (n = 3) f % f % 5. Age at menarche a) < 12 years b) years c) years Duration of menstruation a) 2-3 days b) 4-5 days c) >5 days Frequency of menstruation a) Once in 28 days b) Once in 29-3 days c) Once in days Duration of menstrual pain a) < 12 hrs b) hrs c) >24 hrs Flow of menstruation a) Scanty b) Moderate c) Heavy Nature of menstrual pain a) Pricking b) Throbbing c) Cramping d) Squeezing (Table 1 continues)

45 3 (Table 1 continued) S.No. Demographic Variables Experimental group (n = 3) Control group (n = 3) f % f % 11. Location of menstrual pain a) Lower abdomen b) Back and thighs c) Pubic area d) General body pain 12. Associated symptoms during menstruation a) Nausea b) Vomiting c) Diarrhea d) Giddiness 13. Psychological disturbances during menstruation a) Never b) Occasionally c) Frequently d) Always Using of medication during menstrual pain a) Yes 12 4 b) No Inference of the study due to menstrual pain a) Sometimes missed the school b) Regularly missed c) Missed in one day of their period d) Missed on the second day of menstrual 3 1 period

46 31 Table I shows the description of demographic variables of adolescent girls with dysmenorrhea in experimental and control group. Regarding the age of the adolescent girls, in the experimental group, 18(6%) adolescent girls were between years, 12(4%) were in the age group between years. Among control group, 15(5%) adolescent girls were between years, 15 (5%) were between years. With regard to religion, in the experimental group, 19(63.33%) adolescent girls were Hindu, 8(26.67%) adolescent girls were Muslim and 3(1%) were Christians. In the control group, 21(7%) adolescent girls were Hindu, 2(6.67%) were Muslim and 7(23.33%) were Christians. Considering the education, in the experimental group, 5(16.67%) adolescent girls were in 8 th standard, 11(36.67%) were in 9 th standard, 4(13.33%) were in 1 th standard and 1(33.33%) were in 11 th standard. In the control group, 8(26.67%) adolescent girls were in 8 th standard, 8(26.67%) were in 9 th standard, 5(16.67%) were in 1 th standard and 9(3%) were in 11 th standard. Regarding the BMI, in the experimental group, 1(3.33%) adolescent girl was in less than 2 (under weight), 28(93.33%) was 2-25(optimal weight), 1(3.33%) were in greater than 25 (over weight) and none was in greater than 3 (obese). In the control group, 1(3.33%) adolescent girls were in less than 2(under weight), 28(93.34%) were 2-25 (optimal weight), 1(3.33%) were in greater than 25 (over weight and none were in greater than 3 (obese). With the regard to the age at menarche, in the experimental group, 26(86.67%) adolescent girls attained menarche between the age group greater than 12 years,

47 32 4(13.33%) were between years and none were attained the menarche between years. In the control group, 8(26.67%) adolescent girls attained menarche between the age group of greater than 12 years, 13(43.33%) were between years and 9(3%) were at the age group of years. On considering the duration of menstruation, in the experimental group, 2(6.67%) adolescent girls had 2-3 days duration, 24(8%) had duration of menstruation for 4-5 days and 4(13.33%) had duration for more than 5 days. In the control group, 14(46.67%) adolescent girls had 2-3 days duration of menstruation, 13(43.33%) had duration for 4-5days and 3(1%) had more than 5 days duration. On considering the frequency of menstruation, in experimental group, 12(4%) had menstruation once in 28 days, 15(5%) had once in 29-3 days and 3(1%) had frequency of menstruation once in days. In control group, 2(6.67%) had menstruation once in 28 days, 22(73.33%) had once in 29-3 days and 6(2%) had frequency of menstruation once in days. Regarding the duration of menstrual pain in experimental group, 3(1%) adolescent girls had menstrual pain for less than 12hrs, 22(73.33%) had pain for 12-24hrs and 5(16.67%) had pain for greater than 24 hrs. In control group, 2(6.67%) adolescents girls had menstrual pain for less than 12 hrs, 23(76.67%) had pain for hrs and 5(16.67%) had pain for greater than 24hrs. Regarding the flow of menstruation, in experimental group, 1(3.33%) adolescent girl had scanty flow, 27(9%) had moderate flow, and 2(6.67%) had heavy flow. In control group, 2(6.67%) adolescents girls had scanty flow, 17(56.67%) had moderate flow and 11(36.67%) had heavy flow.

48 33 On considering nature of menstrual pain, in experimental group 3(1%) of adolescent girls had pricking pain, 1(3.33%) had throbbing pain, 24 (8%) had cramping pain and 2(6.67%) had squeezing pain. In control group, 1(3.33%) of adolescent girls had pricking pain, 5(16.67%) had throbbing pain, 23(76.67%) had cramping pain and 1(3.33%) had squeezing pain. Regarding the location of menstrual pain in experimental group, 2(66.67%) of adolescent girls had lower abdominal pain, 9(3%) had back and thighs, 1(3.33%) had pain in pubic area and none of them had general body pain. In control group, 17(56.67%) of adolescent girls had lower abdominal pain, 1(33.33%) had pain in back and thighs, 3(1%) had pain in pubic area and none of them had general body pain. Regarding the associated symptoms during menstruation in experimental group, 3(1%) of adolescent girls having nausea, 19(63.33%) having vomiting, 8(26.67%) having diarrhoea and none of them having giddiness in their periods. In control group, 14(46.67%) of adolescents girls having nausea in their periods, 14(46.67%) having vomiting, 2(6.66%) having diarrhea and none of them having giddiness in their periods. Regarding the psychological disturbances during menstruation in experimental group, 8(26.67%) of adolescent girls had never, 21(7%) had occasionally,1(3.33%) had frequently and none of them had always. In control group, 3(1%) of adolescent girls had never, 22(73.34%) had occasionally, 4(13.33%) had frequently and 1(3.33%) had always.

49 34 Regarding using of medication in experimental group, no one had taken medication. In control group, 12(4%) had taken the medication and 18(6%) had not taken medication. Regarding the inference of the study due to menstruation in experimental group, 24(8%) of adolescents girls were sometimes missed the school, 1(3.33%) were regularly missed the school, 5(16.67%) were missed in on day of the school and no one missed the school in their second day of period. In control group, 5(16.67%) of adolescent girls were sometimes missed her school, 4(13.33%) were regularly missed the school, 18(6%) were missed the on day of school and no one missed the school in their second day of period.

50 Percentage (%) % Experimental Group Control Group 5 5% 5% 4 4% years years Age of the students Figure. 6 Graphical Representation of Demographic Variables of Adolescent Girls According to the Age of the student in Both Experimental and Control Group

51 Percentage (%) % 26.67% 26.67% Experimental Group Control Group 33.33% 3% % 16.66% % 1 5 8th standard 9th standard 1th standard 11th standard Education Figure. 7 Graphical Representation of Demographic Variables of Adolescent Girls According to the Education in Both Experimental and Control Group

52 Percentage (%) % 93.34% Experimental Group 9 Control Group % 3.33% 3.33% 3.33% % % < >25 >3 BMI Figure. 8 Graphical Representation of Demographic Variables of Adolescent According to BMI in Both Experimental and Control Group

53 Percentage (%) % Experimental Group Control Group % % 3% %3 1 < 12 years years years Age at menarche % Figure. 9 Graphical Representation of Menstrual Variables of Adolescent Girls According to Age at Menarche in Both Experimental and Control Group

54 Percentage (%) % Experimental Group Control Group % 43.33% % 13.33% 1% 2-3 days 4-5 days >5 days Duration of menstruation Figure. 1 Graphical Representation of Menstrual Variables of Adolescent Girls According to Duration of Menstruation in Both Experimental and Control Group

55 Percentage (%) 4 9 Experimental Group % 76.67% Control Group % 16.66% 1 1% 6.67% < 12 hrs hrs >24 hrs Duration of menstrual pain Figure. 11 Graphical Representation of Menstrual Variables of Adolescent Girls According to the Duration of Menstrual Pain In Both Experimental and Control Group

56 Percentage (%) % Experimental Group Control Group % % % 6.67% 6.67% Scanty Moderate Heavy Flow of menstruation Figure. 12 Graphical Representation of Menstrual Variables of Adolescent Girls According to Flow of Menstruation in Both Experimental and Control Group

57 Percentage (%) % 76.67% Experimental Group Control Group % 1% 6.67% 3.33% 3.33% 3.33% Pricking Throbbing Cramping Squeezing Nature of menstrual pain Figure. 13 Graphical Representation of Menstrual Variables of Adolescent Girls According to the Nature of Menstrual Pain in Both Experimental and Control Group

58 Percentage (%) % Experimental Group Control Group % % 33.33% 2 1 1% 3.33% % % Lower abdomen Back and thighs Pubic area General body pain Location of menstrual pain Figure. 14 Graphical Representaion of Menstrual Variables of Adolescent Girls According to the Location of Menstrual Pain in Both Experimental and Control Group

59 Percentage (%) % 73.34% Experimental Group Control Group % % 1% 3.33% 3.33% % Never Occasionally Frequently Always Psychological disturbances during menstruation Figure. 15 Graphical Representation of Menstrual Variables of Adolescent Girls According to the Psychological Disturbances During Menstruation in Both Experimental and Control Group

60 45 SECTION II Table. 2 Distribution of Statistical Value of Pre- Test Score Regarding Menstrual Pain Among Adolescent Girls of Experimental and Control Group at Government Higher Secondary School, Kalapatti, Coimbatore (N = 6) S.No. Pretest Pain Score Mean SD t value Level of Significance 1. Experimental group Control group *at significant level Table 2 shows the mean value of pre- test score of pain during menstruation among adolescent girls in experimental group is 5.43 and control group is The calculated t value is.2459 at 58 degree of freedom and at.5% level of significance which is less than the table value(1.98). So it revealed that there was homogeneity between experimental group and control group before providing billig s exercise.

61 Mean Experimental group Control group Experimental group Pretest Pain Score Control group Figure. 16 Graphical Representation of Statistical Value of Pre-test Pain Score Regarding Pain During Menstruation Among Adolescent Girls of Experimental and Control Group

62 47 SECTION III Table.3 Distribution of Statistical Value of Pre- Test and Post- Test Score Regarding Menstrual Pain Among Adolescent Girls of Experimental Group at Government Higher Secondary School, Kalapatti, Coimbatore (n = 3) S.No. Pain Mean SD t value Level of Significance 1. Pretest Post test *.5 *at significant level Table.3 shows that the mean score of pre- test is 5.43 and post test is The calculated t value is at 29 degrees of freedom at.5% level of significance, which is greater than that of table value(2.45). It shows that there was a significant difference between pretest and post test score which implied that there was a significant reduction in menstrual pain after providing Billig s exercise.

63 Mean Pretest Post test Pretest Post test Pain Figure. 17 Graphical Representation of Statistical Value of Pre-test and Post Test Score Regarding Pain During Menstruation Among Adolescent Girls of Experimental Group

64 49 SECTION IV Table. 4 Distribution of Statistical Value of Pre- Test and Post Test Score Regarding Menstrual Pain Among Adolescent Girls of Control Group at Government Higher Secondary School, Kalapatti, Coimbatore. (n = 3) S.No. Pain Mean SD t value Level of Significance 1. Pretest Post test *.5 *at significant level Table.4 shows the mean score of pre- test of control group is 5.47 and that of post test is 5.2. The calculated t value is at 29 degrees of freedom and at.5% level of significance, which is greater than the table value (2.45). This shows that, there was a significant difference between pre tests and post pain score among control group, however not an appreciable difference as in case of experimental group with Billig s exercise.

65 Mean Pretest Post test Pretest Post test Pain Figure. 18 Graphical Representation of Statistical Value of Pre-test and post test Score Regarding Pain During Menstruation Among Adolescent Girls of Control Group

66 51 SECTION V Table. 5 Distribution of Statistical Value of Post Test Score Regarding Menstrual Pain Among Adolescent Girls of Experimental and Control Group at Government Higher Secondary School, Kalapatti, Coimbatore. (N = 6) S.No. Post test Pain Score Mean SD t value Level of Significance 1. Experimental group Control group *.5 *at significant level Table 5 shows that the mean value post test pain assessment during menstruation in experimental group was 1.33 and that of control group was 5.2. The calculated t value was at 58 degree of freedom and at.5% level of significance which is greater than table value (1.98). It shows that the pain score of experimental group was reduced after providing Billig s exercise. Hence alternative hypothesis is accepted.

67 Mean Experimental group Control group Experimental group Control group Post test Pain Score Figure. 19 Graphical Representation of Statistical Value of Post Test Pain Score Regarding Pain During Menstruation Among Adolescent Girls of Both Experimental and Control Group

68 53 SECTION VI Table. 6 Association of Selected Demographic Variables with Post Test Score Regarding Menstrual Pain Among Adolescent Girls at Government Higher Secondary School Kalapatti, Coimbatore (N = 6) S.No. Demographic Variables Above Mean Below Mean Degree of Freedom 2 1. Age of the student a) years b) years Education a) 8 th standard b) 9 th standard c) 1 th standard d) 11 th standard Religion a) Hindu b) Christian c) Muslim BMI a) < 2 (under weight) 1 3 b) 2-25 (optimal weight) c) > 25 (over weight) 1 3 d) > 3 (obese) 3 5. Age at menarche a) < 12 years b) years c) years 2 (Table 6 continues)

69 54 (Table 6 continued) S.No. Demographic Variables Above Mean Below Mean Degree of Freedom 2 6. Duration of menstruation a) 2-3 days 2 2 b) 4-5 days c) >5 days Frequency of menstruation a) Once in 28 days b) Once in 29-3 days c) Once in days Duration of menstrual pain a) < 12 hrs b) hrs c) > 24 hrs Flow of menstruation a) Scanty 1 2 b) Moderate c) Heavy Nature of menstrual pain a) Pricking b) Throbbing c) Cramping d) Squeezing Location of menstrual pain a) Lower abdomen b) Back and thighs c) Pubic area 1 3 d) General body pain 3 (Table 6 continues)

70 55 (Table 6 continued) S.No. Demographic Variables Above Mean Below Mean Degree of Freedom Associated symptoms during menstruation a) Nausea b) Vomiting c) Diarrhea d) Giddiness Psychological disturbances during menstruation a) Never b) Occasionally c) Frequently 1 3 d) Always Using of medication during menstrual pain a) Yes 1 b) No Inference of the study due to menstrual pain a) Sometimes missed the school b) Regularly missed c) Missed in one day of their period d) Missed on the second day of 3 menstrual period Table 6 shows that there is no association of demographic and menstrual variables with post test score on effectiveness of Billig s Exercise in reducing Dysmenorrhoea among Adolescent Girls.

71 56 CHAPTER V Results and Discussion The study aimed at assessing the effectiveness of billig s exercise in reducing dysmenorrhea among adolescent girls. The result of the study is based on the statistical analysis. The data were collected with the help of questionnaire and numerical pain intensity scale. This is two group pretest and posttest quasi experimental study design intended to assess the effectiveness of billig s exercise in reducing menstrual pain among adolescent girls. The result of this study was discussed according to the objective. The First Objective of the Study was to Assess the Level of Dysmenorrhoea Among Adolescent Girls in the Experimental and Control Group Self administered numerical pain rating scale was used to assess the menstrual pain among adolescent girls. The mean score pre- test pain level of experimental group was 5.43 and that of control group was Independent t test was performed to assess whether any significant difference exists in the pretest score of experimental and control group. The obtained t value is.2459 which is less than the table value. This finding reveals that there is homogeneity exists among adolescent girls with dysmenorrhea. Krieger. R. I (21) conducted a study reported that dysmenorrhea is the leading cause of recurrent short term school absenteeism among adolescent girls. The

72 57 data from 2699 menarche adolescent girls of years drawn from a probability sampling method and was collected and analyzed by bivaraite and multivariate analytic technique and out of them 1611 adolescent girls (59.7%) reported dysmenorrhea and 14% frequently miss school because of menstrual pain. The prevalence of dysmenorrhea was lower at age 17 than at 12 years. Gelal. A (29) conducted a study to determine the prevalence and severity of dysmenorrhea among 1826 girls ranged in the age from 13-18years. Questions were asked about general health and about menstruation. 772 girls (53%) responded that they experience pain with their periods. 176(12%) reported discomfort severe enough to necessitate time off work or school. 12% of the total sample reported pain lasting 3 or more days, 36% reported pain 2 or more days. The Second Objective of the Study was to Administer Billig s Exercise for Adolescent Girls with Menstrual Pain in Experimental Group After assessing the pain, the billig s exercise was provided one day before the menstruation and first two days of menstruation,5-6 times at 2 minutes duration to adolescent girls in experimental group and no intervention was given to control group. Hausen. B. M (21) conducted an experimental study to assess the effectiveness of mint on menstrual pain among 12 to 18 years of adolescent girls (n=8). Out of 8, 4 were in experimental group and remaining 4 were in control group. Intervention through billig s exercise was given to the experimental group and routine pharmacological management was given to control group. The study reveals that billig s exercise was very effective in reducing menstrual pain than the pharmacological management.

73 58 The Third Objective of the Study was to Assess the Effectiveness of Billig s Exercise on Menstrual Pain Among Adolescent Girls in Experimental Group Numerical pain scale was used to assess the pain level of adolescent girls with dysmenorrhea after taking the billig s exercise. The mean score of post test pain level was 1.33 in the experimental group and 5.2 in the control group and the calculated t value was This implies that there was more significant difference in the menstrual pain level after taking billig s exercise among adolescent girls of experimental group. Suckling. J (29) conducted a randomized clinical trial study to determine the effect of exercise on primary dysmenorrhea among 15 high school girls in Chennnai city and the result obtained was that the intensity of the pain in the exercise group declined from 8.59 to 4.63 in the third menstrual period and in the fourth menstrual period and 2.84 in the fourth menstrual period.the average of the duration of pain declined from 7.15 to 4.22 in the third menstrual period. In conclusion the exercise can decrease the duration and severity of dysmenorrhea. The Fourth Objective of the Study is to Compare the Level of Dysmenorrhoea Among Adolescent Girls in the Experimental and Control Group Dysmenorrhea of adolescent girls was assessed by numerical pain scale and the result shows that the pretest score of experimental group was 5.43 and post test score was 1.33 and the obtained t value is It showed that there was a significant difference exists between the pre-test and post test, it implied that there was a significant reduction in the intensity of pain after providing the billig s exercise.

74 59 Morse (26) commented that approximately 1% of the women were severely affected by dysmenorrhoea during the reproductive years. Relaxation instructions are provided to experimental group and drug treatment were given to control group. The study revealed that experimental group have significant positive benefits from the relaxation technique.. The Fifth Objective of the Study is to Associate the Level of Dysmenorrhoea Among Adolescent Girls with Selected Demographic Variables Association between level of dysmenorrhea with selected demographic variables was analyzed by using chi square test. The findings after analysis reveals that the demographic variables like age, religion, education, BMI, age at menarche,duration of menstruation, frequency of menstruation, duration of menstrual pain, flow of menstruation, nature of menstrual pain, absenteeism in school showed no significant association with pain score during menstruation. Steven (29) conducted a study to assess the effect of billig s exercise on dysmenorrhea among adolescent girls. 7 adolescent girls were selected for the study by random sampling method. The results found that the variables such as age of the adolescent girls, duration of menstrual flow and body mass index had no significant association with the pain score.

75 6 CHAPTER VI Summary, Conclusion, Nursing Implications, Limitation and Recommendations Summary Dysmenorrhea is the term for describing painful menstrual cramps. It is a common gynecological problem that can affect as many as 6% of adolescent girls, and 15% of these girls suffer severely enough to temporarily render them incapacitated which, results in absences from work or school. The impacts are significant both in terms of quality of life and global economy. The over production of uterine prostaglandins as a substantial contributing factor to the painful cramps that are the major symptom of dysmenorrhea. The present study was to find out the effectiveness of Billigs exercise in reducing dysmenorrhea among adolescent girls at Govt. Higher Secondary School, Kalapatti, Coimbatore. The Following Objectives were Set for the Study To assess the level of dysmenorrhoea among adolescent girls in the experimental and control group. To administer Billig s exercise for adolescent girls with menstrual pain in experimental group. To assess the effectiveness of Billig s exercise on menstrual pain among adolescent girls in experimental group.

76 61 To compare the level of dysmenorrhoea among adolescent girls in the experimental and control group. To associate the level of dysmenorrhoea among adolescent girls with selected demographic variables. The Alternative Hypothesis Set for the Study There is significant difference between pretest and post test pain level after administering Billig s exercise among adolescent girls with dysmenorrhea. So there will be a significant effect of Billig s exercise in reduction of pain during menstruation. Major Findings of the Study are as Follows The pre-test pain mean score of Experimental group was The post test pain mean score of Experimental group was The obtained t value of pain of Experimental group was The pre-test mean pain score of control group was The post test mean score of control group was 5.2. The obtained t value of pain of Control group was The obtained t value for comparison of pre-test pain score was The obtained t value for comparison of Post test pain score was Conclusions The study shows significant effectiveness of Billig s exercise in reducing pain during menstruation among adolescent girls in experimental group. This study shows that the Billig s exercise is more effective in reducing pain during menstruation among adolescent girls than pharmacological management.

77 62 Nursing Implications The finding of the study has implications in various areas of nursing practices, nursing education, nursing administration and nursing research. Nursing Practice If the nurse has knowledge regarding complementary therapies, she can teach this to the patient s so that they will get knowledge on non invasive, non pharmacological treatment without side effects. Nurse can improve the comfort level of the patient. It does not require additional equipment, articles, place or extra precautions. Nursing Education Nursing curriculum is a means through which future nurses are prepared. The nursing curriculum should be updated with the inclusion of topics on complementary and alternative therapies. Dysmenorrhea is the major cause for withdrawl from daily activities and absenteeism in school. Periodic conferences, seminars, symposium can be arranged regarding alternative and complementary therapies to make the nursing professionals competent enough to meet ever changing needs of the society. Nursing Administration The nursing administrators should organize in-service education programme for nurses about the importance of complementary and alternative therapies in nursing practice.

78 63 Nursing Research Nursing researchers should be aware of the new trends and existing health care system. The present study can be used as a motivation for nurses to conduct research in future in comparing different and other alternative therapies to reduce pain during menstruation. Limitations The age group of students limited to years and is limited to only one school. The study was limited to one month period. Recommendations Similar study can be conducted for a large group on a long term basis. Comparative study can be conducted by using various other complementary and alternative therapies to find out the effectiveness in reducing menstrual pain. Comparative study can be conducted between Billig s exercise and pharmacological treatment.

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82 D Scully (28) Exercise and Primary dysmenorrhoea. Journal of sports medicine. Volume 38, Issue 8, Duran, E. T,et. al. (212).Traditional practices for gynecologic complaints.vol.11 (3) French. (29). Primary dysmenorrhea. Journal of Cochrane Database System Review. Vol.3. Jackson, C. (21). Dysmenorrhea. Journal of African Traditional Complementary Alternative Medicine. Vol. 8 (5) Jenner. (27). Primary dysmenorrhea. Womens health. Vo. 38 (3) Jerdy S, (212). Effects of stretching exercise on primary dysmenorrhoea in adolescents girls. Journal of Biomedical Human Kinetics. 1(4) Julie A Aganoff. (1994). Aerobic exercise, mood states and menstrual cycle symptoms. Journal of Psychosomatic research. Volume 38, Issue 3, page no Kaupila A,et. al (29). Treatment of primary dysmenorrhea. European Journal of Gynecology and Reproductive biology Kerns, M. (28). European Medicines Agency Evaluation of Medicines for Human Use. Lee K K et.al (26). Menstruation among adolescent girls in Malaysia Singapore. Medical Journal ; 47(1) : Liping Wong (21). Dysmenorrhoea in a multiethinic population of adolescent Asian girls. International Journal of Gynaecology and Obstetrics. Volume 18, Issue 2, Morse (26). Effects of relaxation technique in pain reduction. Nursing and Midwifery Research Journal, Volume 8 No-5

83 Ortiz M I (29). Prevalence and impact of primary dysmenorrhoea among Mexican high school student BJOG 17: Ozlem Onur (212). Impact of home based exercise in quality of life of women with primary dysmenorrhoea. South African Journal of Obstetrics and Gynaecology, volume 18. Patlison H. M (29). To assess the effects of exercise on dysmenorrhoea in Taiwan. Indian Journal of Community Medicine, Volume -3.No-1 Panchangam S Primary dysmenorrhoea in young 1women; prevalence, impact and knowledge of treatment. Indian Journal of community medicine. Rima Gupta et.al (213). Comparison to assess the effectiveness of active exercise and dietary ginger vs active exercises on primary dysmenorrhoea among adolescent girls. Nursing and Midwifery Journal. Volume 9. No-4. Santina T (21),Exploring dysmenorrhoea and menstrual experiences among Lebanese female adolescent. International Journal of Gynaecology and Obstet. Volume 5 Selvaraj, (28). Dysmenorrhea in adolescents. Nightingale nursing times. Vol. 2 (2). 8-1 Shahnaz, S. J and Rahman, S. H, et. al. (212). Primary dysmenorrhea in adolescent girls. Journal of biomedical human kinetics. Vol. 4 (1) Unsal A (21). Prevalence of dysmenorrhoea and its effect on quality of life among a group of female university student, Upsala journal of medical science 115/ Wan,P. A and Zhang, W. Y. (28). Efficacy of minor analgesics in primary dysmenorrhea: a sysyematic review. Journal of Obstetrics and Gynecology. Vol. 15 (7)

84 Westhoff, C and Connell, O, et.al. (29).Self treatment patterns among adolescent girls with dysmenorrhea. Journal of Pediatric Adolescent Gynecology. Vol. 19 (4) William P Metheny and Roger P Smith (1989). The relationship among exercise, stress and primary dysmenorrhoea. Journal of behavioral medicine.volume 12 No -6. Online Abstract Agarwal, A. K, et. al. (21).A study of dysmenorrhea during menstruation. Retrieved from med.com Alan, R. (29).adolescence stage. Retrieved from Com Banikarim, C. (212). Primary dysmenorrhea in adolescents. Retrieved from Chen, L. I. (29). Dysmenorrhea and related factors. Retrieved from Cynthia, F,et. Al. (21). Diagnosis and management of dysmenorrhea. Retrieved from Francoise. (212).Adolescent dysmenorrhea. Retrieved from Fraser.(29).dysmenorrhea. Retieved from French, L.A. (211). Dysmenorrhea in adolescence. Retrieved from French, L. (29).Dysmenorrhea. Garley. R. M. (211). Dysmenorrhoea.Retrieved from Gregory J Boyle(24). Review exercise and primary dysmenorrhoea.retrieved from

85 Harel, Z. (29).dysmenorrhea in adolescence and young adults. Retrieved from Jackson, C. (21). Adolescent dysmenorrhea. Retrieved from Keane, M. (21). Menstruation- everything you must know. Retrieved from Latthe. P. M (211). Dysmenorrhea. Retrieved from www. clin evid.com Lubbe, A,et.al (211). Dysmenorrhoea. Retrieved from net.com Maître Shah (213), A study of prevalence of primary dysmenorrhoea in young students. Retrieved from Malhotra, C. (28). Type and frequency of problem of menstruation. Retrieved from Mariyam Rostami (27).treatment approaches for dysmenorrhea. Retrieved from Morrow, C. (29). Dysmenorrhea. retrieved from Ortiz, M. I (21) primary dysmenorrhea-prevalence, impact, treatment. Retrieved from Pattison, H. M. (29) Effect of acupressure on dysmenorrhea. Retrieved from Prof. Dr. B. T. Murthy, C. (29). Menstruation. Retrieved from Saha, R. (211). Primary dysmenorrhea. Retrieved from Suckling, J. (29). Exercise to reduce dysmenorrhea in adolescence. Retrieved from Swank, C. O. (29). A clinical study on pain intensity in dysmenorrhea. Retrieved from

86 Taneja, D. K. (28). Primary dysmenorrhea. Retrieved from Unpublished Thesis Hemambika (212). Effectiveness of group of exercise on menstrual problems among adolescent girls in selected colleges, Calicut,Unpublished masters dissertation. Calicut University of Health Sciences, Calicut kerala. Jima Mathew (213). An experimental study was conducted to the Effectiveness of Billig s exercise on Dysmenorrhoea among adolescent girls in selected schools at Mangalore. Unpublished masters dissertation Rajiv gandhi University of Health Science, Karnataka, Bangalore. Ms.Jitha P Thomas (213). A Study to determine the effectiveness of pelvic floor exercise in reducing dysmenorrhoea among adolescent girls studying in selected schools of Bengaluru. Unpublished masters dissertation Rajiv Gandhi University of Health Science. Karnataka. Bhavika Rathod (213). A Study to determine the effectiveness of pelvic floor exercise in reducing dysmenorrhoea among adolescent girls studying in selected schools of Bengaluru. Rajiv Gandhi University of Health Science, Karnataka.

87 ABSTRACT Statement of the Problem: A study to assess the effectiveness of Billig s exercise in reducing dysmenorrhea among adolescent girls at Government Higher Secondary School, Kalapatti, Coimbatore. Study Objectives: (a) To assess the level of dysmenorrhoea among adolescent girls in the experimental and control group. (b) To administer Billig s exercise for adolescent girls with menstrual pain in experimental group. (c) To assess the effectiveness of Bulig s exercise on menstrual pain among adolescent girls in experimental group. (d) To compare the level of dysmenorrhoea among adolescent girls in the experimental and control group. (e) To associate the level of dysmenorrhoea among adolescent girls with selected demographic variables. Methodology : experimental approach, a subtype of quantitative approach, two group pretest and posttest quasi experimental design was used for the present study. The sample for the study consists of 6 adolescent girls with dysmenorrhea, 3 in experimental group and 3 in control group, selected by purposive sampling techniques, a type of non probability sampling method. Numerical Pain Intensity Scale was used to assess the level of menstrual pain of adolescent girls in both groups. Results : Inferential and descriptive statistics were used to analyze the data. The pretest value of menstrual pain in adolescent girls for experimental and control group was 5.43 and 5.47 respectively.the mean post test score was 1.33and 5.2 for the experimental and control group. The comparison was done between two groups by performing the independent t test and the value was Conclusion : The study shows that the Billig s exercise is effective to reduce menstrual pain among adolescent girls

88 To The Managing Director, Ashwin Hospital, Coimbatore. Through The Principal, PPG College of Nursing Coimbatore 35. Respected Sir, Sub : Seeking permission for conducting research study I am a student of M.Sc Nursing in PPG College of Nursing. Our college is affiliated to the Tamilnadu Dr. M. G. R Medical University, Chennai. I have taken the specialization in Obstetrics and Gynecological Nursing. Topic : A STUDY TO ASSESS THE EFFECTIVENESS OF BILLIG S EXERCISE IN REDUCING DYSMENORRHEA AMONG ADOLESCENT GIRLS AT GOVERNMENT HIGHER SECONDARY SCHOOL, KALAPATTI, COIMBATORE I request you to kindly permit me to conduct my study in your institutions. Hope you will consider my requisition and do the needful. Date : Place : Coimbatore Thanking you, Yours sincerely,

89 Requisition Letter for Content Validity From M.Sc (N) II Year, PPG College of Nursing, Coimbatore 35. To Through : Principal, PPG College of Nursing Respected Sir/Madam, Sub : Requisition for expert opinion and suggestion for content validity of tool I am a student of M.Sc (N) II year, PPG College of Nursing affiliated to the Tamilnadu Dr. M. G. R. Medical University, Chennai. As a partial fulfillment of the M.Sc (N) programme. I am conducting A STUDY TO ASSESS THE EFFECTIVENESS OF BILLIG S EXERCISE IN REDUCING DYSMENORRHEA AMONG ADOLESCENT GIRLS AT GOVERNMENT HIGHER SECONDARY SCHOOL, KALAPATTI, COIMBATORE Herewith I have enclosed the developed tool for content validity and for the expert opinion and possible solution. It would be very kind of you to return the same as early as possible. Thanking you, Yours faithfully,

90 PPG College of Nursing Format for the Content Validity Name of the expert : Address : Total content for the tool : Kindly validate each tool and tick wherever applicable S.N o No. of Tool/Sectio n Strongl y Agree Agre e O. K Not Applicabl e Need Modificatio n Remark s Remarks Signature of the Expert with Date

91 LIST OF EXPERTS 1. Prof. S. RENUKA, M.Sc (N)., Department of Obstetrics & Gynecology KMCH College of Nursing Coimbatore. 2. Prof. MUMTAZ, M.Sc (N)., Department of obstetrics & Gynecology Annai Meenakshi College of Nursing Coimbatore. 3. Prof. CHARMINI JEBAPRIYA, M.Sc (N)., Principal, Texcity College of Nursing Coimbatore. 4. Prof. ESTHER JOHN, M.Sc (N)., Principal Ganga College of Nursing Coimbatore. 5. Prof. V. KAVITHA, M.Sc (N)., Professor Sri Ramakrishna College of Nursing Coimbatore.

92 PART - A Demographic Variables Instruction Read every statement carefully and indicate the response that you choose by placing a tick () in the appropriate space given. Sample No. : 1. Age of the student a) years b) years 2. Education a) 8 th standard b) 9 th standard c) c.1 th standard d) d. 11 th standard 3. Religion a) Hindu b) Muslim c) Christian 4. Body mass Index ( Quetilet s Index ) a) < 2 ( underweight ) b) 2-25 ( optimal weight ) c) >25 ( over weight ) d) > 3 ( obese )

93 Menstrual Variables Instruction Read every statement carefully and indicate the response that you choose by placing a tick () in the appropriate space given. 1. Age at menarche a) <12 years b) years c) years 2. Duration of menstruation a) 2-3 days b) 4-5 days c) >5 days 3. Frequency of menstruation a) Once in 28 days b) Once in29-3 days c) Once in days 4. Duration of menstrual pain a) < 12 hrs b) hrs c) > 24 hrs

94 5. Flow of menstruation a) Scanty b) Moderate c) Heavy 6. Nature of menstrual pain a) Pricking b) Throbbing c) Cramping d) Squeezing 7. Location of menstrual pain a) Lower abdomen b) Back and thighs c) Pubic area d) General body pain 8. Associated symptoms during menstruation a) Nausea b) Vomiting c) Diarrhea d) Giddiness 9. Psychological disturbances ( anger or irritation ) during menstruation a) Never b) Occasionally c) Frequently d) Always

95 1. Using of medication during menstrual pain a) Yes b) No 11. Inference of study due to menstruation a) Sometimes missed the school b) Regularly missed the schools c) Missed on the first day of their period d) Missed on the first 2 days of their period

96 PART - B Numerical Pain Intensity Scale No pain Mild Pain Moderate Pain Severe Pain Description : None 1-3 : Mild pain 4-7 : Moderate pain > 7 : Severe pain

97

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102 PROTOCOL BILLIG S EXERCISE Introduction Menstruation is monthly bleeding from the uterus which occurs for 4-5 days every 28 days during the reproductive life of women, with an average blood loss of about 2-6 ml of blood. It is often associated with problems of irregular menstruation, excessive bleeding and dysmenorrhoea. Of these dysmenorrhoea is one of the common problems experienced by many adolescent girls. Dysmenorrhoea is defined as a painful menstruation caused by natural chemicals called prostaglandins. Pain usually occurs right before menstruation starts, as the level of prostaglandins increases in the lining of uterus. On the first day of menstrual period, the prostaglandin levels are high. Pain usually decreases as the level of prostaglandins decrease. So the pain can be experienced few days before the periods starts and lasts for 1-2 days of period. Dysmenorrhoea is of two types. Primary dysmenorrhoea and secondary dysmenorrhoea. Of this primary dysmenorrhoea occurs in young females with no pelvic pathology. It often begins with the onset of ovulatory cycles six months to one year after the menarche. Billig s one of the first advocates of exercises for dysmenorrhoea, in When a women with dysmenorrhoea has a contracted ligamentous bands in the abdomen, while exercising subsequently developed a series of stretching in the

103 abdomen and pelvic muscles, which claimed a high rate of symptom relief. Billig s exercises is pelvic tilt along with tightening of buttocks and muscles of abdomen followed by relaxation. This exercise was beneficial continued to enjoy widespread acceptance. It has been proven to be safe by the WHO and the US National Institute of Health (NIH) among other reputed research institutions. Benefits of Exercises It helps to improve physical strength and stamina. It improves blood circulation and reduce pain. It also reduces psychological stress. Any type of exercises can be practice in our daily life, such as simple running, skipping, walking and breathing exercise. Pre Requisites for Billig s Exercise Before starting the exercises The bladder should be empty. Soon after full stomach meal, should not do exercises. Select open and well ventilated place for doing exercises. Wear loose cloths while doing exercises. Some easy and practicable exercises are explaining here. Before going to do the exercises should warm up our body first. Billigs exercise can done at any time but, the most appropriate period is 2 days before menstrual period and during the time of menstruation

104 Mainly Two Types of Exercises Warm up Stretching Easy pose Butterfly stretch Regular crunches Reverse crunches Relaxation Warm up The aim of the general warm up is simply to elevate the heart rate and respiratory rate. This in turn increases the blood flow and helps with the transportation of oxygen and nutrients to the working muscles. This also helps to increase the muscle temperature, allowing for a more effective static stretch. Method of Warm up Stand simply. Take a deep breath to set up. Keep both hands on your waist. Tilt the head to all sides for 3minutes. Tilt your shoulders clockwise and anti clockwise direction. Then rotate both hands inwardly and outwardly.then simple jog for 2 minutes. Come to straight. Hold both hands up, stretch side to side and forward, then came to normal position.

105 Exercise - I Easy pose Sit down on the floor. Cross your legs. Clasp your hands around the knees. Exercise - II Butterfly Stretch

106 Do the butterfly yoga pose: First, sit on the floor with your back straight. Slowly bring the soles of your feet together. Hold on to your ankles, and let your knees drop as close as they can to the floor. Your legs should form a little diamond shape in front of you. Don't force your knees down or pull your feet in toward your groin. Close your eyes and take 5 deep breathes. Exercise - III Regular Crunches

107 Lie down on the floor (you can use a floor mat to rest on). Bend your knees and then hold your hands below the neck. Now, while exhaling, lift the upper part of your body. Remember, do not tuck your chin in the chest, your chin must be in a straight direction. Then while inhaling, go in the downward direction. Repeat the crunches 2 times. Exercise - IV Reverse Crunches Start the exercise by lying flat on your back, with your head on the floor and your arms behind your neck. Raise your feet to the air, keeping your knees slightly bent and then crossing your feet at the ankles. These create tension in the body to that the slightest move will affect the abdominal muscles. Lift your hips off the floor, keeping your back as straight as possible on the floor, hold at the top position, squeeze

108 in your abdominal muscles for added effect, and then lower your hips back to the floor. Then repeat. Exercise - V Pelvic Tilt Lie on flat. Bend your knees. Both hands to be the sides of the body. Strengthen the abdominal muscle, force the back to wards the floor and raise the pelvis. Continue this position for 1 seconds and relax. Repeat the same for 1 times. After the exercise relax for 1 minutes. Relaxation